Direct Patient Care Documentation Darrell Johnson.docx - 1...

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1 Clinical Learning Direct Patient Care Documentation Sept/2020
2 Table of Contents NR 226 DIRECT PATIENT CARE DOCUMENTATION Submit in the Weekly CLA drop box each virtual clinical day May be hand written or typed I-SBAR on iHuman patient for the virtual clinical day ..................................................................................... 3 Nursing Skill ALT (Use ALT template to complete) .......................................................................................... 4 Healthcare Provider Orders ....................................................................................................................... 5 &6 Concept Map ................................................................................................................................................. 7 Reflection paper (1 paragraph only) ……………………………………………………………………………………………………………8 Nurses Note (already completed in the iHuman) ……………..…………………………………………………………………………8 Sept/2020
3 Sept/2020 128/74 68 22 37.1 C 99% 0/10 I Introduce yourself Your Name: Jimmy Yip Your Title: Student Nurse Reason for being there: I am here to take a complete neurological and physical assessment S Situation Patient: Darrell Johnson Age: 64 Gender: Male Height/Weight: 183cm/75kg Allergies: No known Code status: Full Privacy Code: Pineapple Time: 1400 Attending Physician: Dr. Porter Patient Chief Complaint: Hand Tremors Admitting Diagnosis: Medication adjustment for worsening/preexisting Parkinson’s Admission Date: Day 1 1400 B Background Past Medical History : Parkinson’s and a Tonsillectomy Social History: Mother died at 80 from stroke. Occasional beer drinker. 1 or 2 a week No history of tobacco or substance use. Regular diet and sedentary lifestyle.

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